TLDR:

A 68-year-old woman fell at home and suffered a left femoral neck fracture. She had stage IV lung ca with bilateral upper lobectomies - on chemotherapy and dexamethasone. The pulmonology service cleared her, advising she may need stress steroids. Two other anesthesiologist had declined the case.

Case goes okay, some hypotension after induction. Patient is unresponsive in pacu. CT concerning for shower emboli. Patient goes comfort care, husband sues. "Expert" testimony blames it on not given stress dose steroids on induction. Per anesthetist, they were given just not documented. Hospital was dismissed because the anesthesia group was an outside contracted group.

Peds fellow here struggling a bit with ultrasound guided IVs on infants/neonates. I feel like I’m okay once they’re above age 2 or so, but these small superficial ones are giving me issues.

Any tips or advice for improving stabilization and needle visualization? Recently I’ve tried using tape to help get the skin taut and the secure limb which I think has helped somewhat. I feel like I struggle the most with visualizing the needle tip once it enters the skin, and often I’m already too deep by the time I find it.

I'm an emergency medicine resident and I recently attended a pediatric anesthesiology presentation. The main speaker (ped anesthesiology fellow) said there's a massive disconnect between evidence based guidelines and what actually happens in the hospital. He said 1hr fluid cut off doesn't bump up aspiration risk and some of the newer research proves it. In his opinion, the NPO after midnight doesn't help the children and more frustrating for the parents. He said hospitals should be moving away from that rule.

Other people at the presentation disagreed with him and there was a lot of Q&A.

Hello all,

Anesthesia trainee here. I have a quick question regarding narcotic titration at the end of a case.

I’ve always heard to titrate narcotic to a RR 8-12 (looking at HR/BP as well) for adequate analgesia pre-extubation.

My question is does this strictly apply to spontaneous ventilation when they’re fully reversed or can you gauge off of PSV as well?

I’ve noticed my RR changes going from PSV to spontaneous. Does this mean when they’re triggering on PSV, it’s not a true reflection of pain status and shouldn’t be considered when working in narcs?

TIA

Anyone know anything about working here? I understand they’re probably in a state of transition with the new residency program. Any details would be great, thanks!

Does anyone have experience working at OSU Wexner, what’s it like? I’m from out of state but have in-laws, considering moving to Columbus in general for job after residency.

How does one conduct a discreet job search without current employer finding out? Some places require letters of rec even before offering interview, and I don’t want anyone at current workplace to know I’m looking elsewhere. For context this is my first job after residency. To ask prior workplace would mean going back to residency attendings who may/may not still work there…

I have anxiety that means I sometimes have to take Ativan. I made a post on r/Anesthesia and they were a little negative, saying I should get my mental health in order before even beginning to think about anesthesia as a career. The thing is, I have anxiety that is likely not going to go away, and the therapy I'm working on tells me to accept that and still push myself to do the career that is my dream. But I want to know, can I work, or be on placement as a student, while taking Ativan? I don't take it daily but I'd likely need it for example for the first day of placement or of work. I only take 0.5 mg and it doesn't impair me.

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AI photo Based on recent (and frequent) events

- Yes I'm being dramatic 😅

Anyone know what’s going on in Hot Springs, AR? I’ve gotten like 8 texts/calls about a locums gig there since Monday. I always mark locums calls as spam so it’s from different numbers and my colleagues are getting hit hard about this specific gig too. It seems like they are wildly desperate and I’m curious if there was a mass exodus or something that prompted this.

Graduating from residency in the western part of the country and want to return home to where I grew up for family reasons so I’m pretty set on geo location.

I know Envision runs most of the show down there with some pretty mediocre salaries, can anyone shed some light on other options or point me in a better direction or am I going to be stuck as a slave to private equity?

I usually feel comfortable with 18g x2 for lower risk stuff or 18 and 16 if I think there may be a need for blood etc. I’ve been noticing a lot of colleagues insisting on 16 and 14, or 14 and 14 which just seems like a lot. Most of the time these cases come out of the OR with the 14 gauge unused (like not even got fluids). Am I being too comfortable with smaller access?

I’m talking about stuff like laparoscopic hemicolectomies etc

UK registrar here who loved their cardiac block but finding it difficult to navigate what the current recent appointee has on their CV to distinguish themselves. Obviously the cardiac SIA and additional fellow year is a given, but beyond that are recently appointed consultants needing MDs/PhDs or a similarly research-heavy CV to get ahead?

Where I did my cardiac block the vast majority of consultants were much older and as a result their pathway into their job looked vastly different to those fighting it out in the current climate. Essentially I'm trying to figure out if I should give up on the dream and instead try and focus my energy into making myself as employable as possible as a general anaesthetist, seeing as how funding is drying up for consultant posts up and down the country. Thanks in advance.

Attending Anesthesiologist

Generally my approach to doing an H&P for my anesthesia note consists of a chart review: relevant labs, studies, notes (eg, PCP, cards, pulm) and then a brief verbal discussion with patient: Anes hx/fmhx issues with anes, cardio(eg. MI, cardiac devices), pulm(eg. COPD,Asthma, OSA), neurologic(eg. SZ, CVA) endocrine(eg. DM) My review with the patient is pretty bare bones since I’ve usually obtained most information from a chart review, but there are a few questions I want to double check. It also helps establish rapport.

Sometimes, patients who are either elderly, very nervous, or both do not answer the questions I ask them as these patients commonly tend to have circumstantial and/or tangential thought processes.

IMO ideally, I would have an infinite amount of time to redirect the patient multiple times for each question I ask, but in the real world, it’s going to likely cause a lot of animosity towards me by the rest of the OR staff for taking excessive amount of time. Therefore what I’ll usually do in these circumstances is to forgo the remainder of my questions if the patient doesn’t give me a straight answer as to whether they have a personal or family history of issues with anesthesia (generally my first question). I figure the situation is analogous to not being able to ask a child/delirious person/etc for their history. I already likely have the information I need from a chart and the verbal questions are probably going to be low yield in a patient that can’t stay on topic.

Is this what everyone else does? Or how do you approach your H&P in the elderly?

Attending anesthesiologist. Practice in multiple hospitals as a locums.

I was wondering what everyone discusses in their pre-operative consent spiel.

Frequently, I am told by patients that had multiple surgeries that I am the first one that ever mentioned any risks to them. Also, sometimes Ill overhear other anesthesiologists doing consent and many don’t disclose any risks.

Personally, I mention the following risks for GETA:

Dental injury, sore throat, ocular injury, nerve/positional injury, nausea, pain, blood transfusion & possible side effect. Major injury eg pulmonary, neurologic, cardiac. I then at the end solicit for any questions. I don’t discuss the details of anything unless the patient asks questions

This takes me very little time. Probably approx 1 minute just to briefly list the potential risks.

SRNA looking for thoughts on a case today.

Patient had no respiratory history, normal EF, and normal hemodynamics after induction. During robotic fundoplication, the patient became persistently tachycardic and hypotensive enough to require a vasopressor infusion. Towards end of case I was on around 70% FiO2 with 8 of PEEP. Sats were in low 90’s

At the end of the case, I noticed significant subcutaneous emphysema with periorbital swelling. That made me concerned that the earlier hemodynamic and respiratory changes may have been from a CO₂ capnothorax with tension physiology.

In PACU, the patient was still requiring 8 L O₂ and saturating around 90%, so I suggested a CXR. Patient was still tachy and hypotensive, and uncomfortable from all the gas.

Would you consider that overall picture concerning enough for capnothorax/tension physiology? Would you get a CXR or lung ultrasound postop with that persistent oxygen requirement?

I ended getting CXR which showed small bilateral apical PTX.

Can anyone give tips on how to network successfully at the ASA conference as a medical student and just give general advice on the conference

As an employer and business entity, anyone have experience with them that you could share publicly or privately?

https://www.instagram.com/summitanesthesia_az?srtk=MWlpdjduaWJzbjJlbQ==

EM resident currently on my anesthesia rotation. I’ve had about 27 intubations under my belt over the past week, and one thing I consistently struggle with is advancing the ET tube through the cords.
I’m using a GlideScope, and I can usually get a good view of the vocal cords without much difficulty. However, when I try to advance the tube, it frequently gets hung up around the larynx despite having a clear view.
The anesthesiologists have been telling me to rotate or twist the tube to help it pass, which makes sense, but for whatever reason I don’t understand the direction and why it goes through with a twist, I struggle to remember to do that in the moment.
I’m wondering if anyone else struggled with this early on and what helped you improve. Are there any specific techniques, hand movements, or mental cues that made passing the tube easier?
I’d appreciate any tips, especially from people who regularly use video laryngoscopy.

Any thoughts on ultimate board preps courses, specifically the gold plan vs ultimate? Trying to figure out if this is the way to go. Thanks!

How do you like your job? Are the shifts sustainable when 1 week on and 1 week off? I’ve never done night shifts but there are more and more nocturnist jobs out these days and I’m wondering whether it would be a good fit but wanted to see how other night docs felt first!

New to peripheral blocks. Started a job in a big orthopedic centre and blocks are routine in this facility. Do you have a specific approach when you were learning how to do them?
I have downloaded ANSO and started watching bunch of YouTube Nysora videos. Any other tips?

CA-1 equivalent here (2 months in), and we got no intern year, so we get thrown straight into grinder after med school. In Ukraine, Anesthesiology and Critical Care are a single unified residency, but given the severe physician and nursing shortages right now due to the war and them bombing our hospitals, our daily workflow is intensely fragmented. On any given call, we're balancing the OR while acting as the primary code and airway team, running lines and sedation for CT and IR and spend time at the ED (yes, we are EM too) alongside our ICU load alongside 24 hour shifts which we have to do few times a month. And yeah, was my experience since day one.

I love it here, but the learning curve in the residency is kicking my ass. I've managed to induce, intubate, run cases (TIVA ones mostly) under attending supervision, but imposter syndrome is hitting hard. I feel like I should know significantly more than I do at this stage, same as in ICU. Or maybe it's because we do the work of CRNA, anesthesiologist, CCM doctor, ICU nurse and orderly - so I have no sense of my purpose, which is kind of fucking me up, it made me feel lost but I shall keep on going.

So my question and what I need help with

1. Best book to work with: what are the gold-standard, high-yield introductory books for a resident, since I rely on AMBOSS, is it also good resource?

2. Best digital, FOAMed, podcasts, Youtube, apps to use

3. Tips I should know as CA1. It is a bit harder with ADHD, but doable. How should I study properly, what should I do to improve, any tips in general.

I appreciate any advice and tips, love y'all.

I think my book knowledge is probably above average, but at least it is certainly not critically deficient. But I still struggle so much with the procedures and workflow, particularly with sicker patients. Especially when I have a currently hospitalized add-on I get so overwhelmed with trying to wrap my head around their physiology during my previous case, while also drawing things up, etc, and then especially if ICU transporting with a million lines that all get tangled, moving to bed, etc are such a challenge. I also struggle under pressure; many of the common less challenging OR scenarios (I was trying to think of a list but honestly 90% of the time it is just hypotension/bradycardia) I can handle but if something is an actual problem (such as for example, true disasters like asystole or a need for front of neck access, or semi disasters like large and quick blood loss) I am totally hopeless with cognitive overload. We had a few simulation sessions recently and I seriously had no idea what to do in any of them.

I am also constantly so stressed. When I was an intern, unless your mistake was not calling a rapid response/code, you had hours to realize a mistake before it would harm a patient. In anesthesia, you could kill someone nearly instantly if you mess up a dilution or push the wrong thing, or even by inaction you could kill someone pretty quickly, a lot more quickly than on the floor. Sure for many things there is time to call overhead and someone who actually knows what they're doing will come within 120 seconds, but 120 seconds is an eternity in some pathologies. When I have expressed this, usually the response is something close to "oh yeah you'll kill some people that's residency" which doesn't exactly seem right to me...I know a career without a single big mistake is unrealistic, but still...

Now I do understand that I am not seeing the other CA1s in action and so perhaps they have all the same experiences, but hearing them talk it really does not seem like this is that hard for them. I find it pretty hard to believe they are both as bad as me and also so overconfident they don't perceive it. I also understand that this is a 3 year residency for a reason, but learning is often logarithmic and we are decently far into CA1. I had hoped I would have a better handle on the basics by now so that I could start focusing on learning more in-depth things. I am really starting to think that this might not be the field for me.

Has anyone else dealt with this in your CA1 year (particularly those who are now later in residency or graduated)? Is this at all normal or am I just cooked?